If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Corresponding author: Jacob Brubacher, MD, Department of Orthopedic Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 3017, Kansas City, KS 66160.
Distal forearm fractures are prevalent among the Medicare population. Many patients who sustain these fractures have poor bone health and are at increased risk for subsequent fractures. We sought to determine the rate of bone mineral density (BMD) testing and subsequent fragility fracture-free interval after distal forearm fractures in the Medicare population.
Methods
We examined the 5% Medicare Standard Analytic File dataset using the PearlDiver Application from 2005 to 2014 to identify patients with distal forearm fractures based on International Classification of Diseases–Ninth Revision and Current Procedural Terminology codes. We queried these records to determine the incidence and timing of BMD testing after fracture and the number of patients who went on to hip or vertebral fractures. Survival curves were generated using Kaplan-Meier analysis with hip or vertebral fracture as the end point.
Results
A total of 37,473 patients with distal forearm fractures were identified who did not have BMD testing within the 2 years before fracture. Only 9,605 of this unscreened cohort underwent testing after the fracture (26%) and only 2,684 underwent testing within 6 months (7%). The patients least likely to be tested were males (9%), those aged over 85 years (12%), and those less than 65 years (22%). Twenty percent of these patients sustained a subsequent hip or vertebral fracture (n = 7,326). Patients who underwent testing after fracture had a longer fracture-free interval compared with patients without BMD testing (819 vs 579 days). When separated by sex and controlling for comorbidities, males with BMD testing had a worsened fracture-free interval whereas females had an improved fracture-free interval.
Conclusions
Bone mineral density testing is underused nationwide in patients sustaining distal forearm fractures despite current guidelines. Orthopedic surgeons should ensure proper testing of patients because this may be an important time point for intervention.
Dr. Graham interviews Dr. Jacob Brubacher regarding his article "Rate of Bone Mineral Density Testing and Subsequent Fracture-Free Interval After Distal Forearm Fracture in the Medicare Population”, which is the lead article for the April 2021 issue of the Journal of Hand Surgery.
Distal forearm fractures are often the first clinical manifestation of low bone mineral density (BMD). It is estimated that more than 10 million Americans are affected with osteoporosis, whereas another 43 million have low BMD, most of whom are female.
Patients with low BMD have increased risk for fracture from low-energy mechanisms. Osteoporosis-related fractures account for over 2 million fractures and 400,000 hospitalizations annually.
It is estimated that osteoporosis will be responsible for more than $25 billion in annual health care spending by 2025, as the US population ages at an unprecedented rate.
Worldwide, the group aged 65 years and older is expected nearly to triple from 617 million in 2015 to 1.6 billion in 2050 whereas the group aged 80 years and older is expected to more than triple from 126 to 446 million.
This puts a considerable burden on the health care economy as use and spending increase with patient age, partially as a result of preventable low-impact fractures.
Fragility fractures include hip, vertebral compression, humeral, and distal radius fractures sustained from low-energy mechanisms. Each has an important impact on the lives of patients and cost to society. Elderly patients with hip fractures consistently have impaired activities of daily living and a 15% to -30% mortality rate at 1 year after fracture.
Osteoporotic vertebral compression fractures are the most common fragility fracture, with a prevalence of 5% to 10% in patients aged 50 to 60 years and greater than 40% in patients aged over 80 years.
Thus, they offer an opportunity for intervention to decrease risk for more morbid fragility fractures. Prior studies indicated low rates of screening for osteoporosis among patients with low-impact fractures despite several national guidelines urging testing.
Several osteoporosis screening guidelines are available to clinicians. The US Preventive Services Task Force, National Osteoporosis Foundation, American Association of Clinical Endocrinologists, American College of Endocrinology, and Endocrine Society each have published guidelines on screening for osteoporosis.
American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis - 2016.
Specific recommendations for fragility fractures vary, but the consensus is that adults with fractures from low-energy mechanisms should undergo BMD testing if they have not been tested in the previous 2 years. Despite Medicare coverage for testing every 2 years, most patients with fragility fractures, including those with distal forearm fractures, go untested.
As a result, important opportunities for intervention are missed and patients are at increased risk for subsequent fracture.
The purpose of this study was to determine the rate of BMD testing and subsequent fracture-free interval in a national cohort of elderly Medicare patients who sustained a distal forearm fracture. Our hypothesis was that the rate of screening for osteoporosis would remain low and that patients who underwent BMD testing would have a longer fracture-free interval in terms of subsequent hip or vertebral fracture.
Materials and Methods
We examined the Medicare Standard Analytic File dataset using the PearlDiver application (PearlDiver Inc) from 2005 to 2014 to identify patients with distal forearm fractures. PearlDiver is a national database of insurance billing records that can be used to identify patients based on International Classification of Diseases–Ninth Revision (ICD-9) and Current Procedural Terminology billing codes. The Medicare Standard Analytic File dataset represents 5% of the Medicare population and contains inpatient and outpatient facility billing records as well as physician billings records. All records are Health Insurance Portability and Accountability Act compliant and contain no individual patient identities. The database is stored on a password-protected server maintained by PearlDiver. Institutional review board approval was not required for the study because all data were deidentified.
To identify patients with distal forearm fractures, we queried the database for the appropriate ICD-9 diagnosis codes (Table 1) to include various distal radius and/or ulna fractures from 2007 to 2013. We only included patients with fractures starting in 2007 to ensure that up to 2 years of records were available before fracture. We excluded patients with less than 6 months of records after fracture. Patients with a BMD scan within the 2 years preceding fracture were also excluded. Two years was chosen because it is the interval during which Medicare will cover repeat testing. Patients receiving osteoporosis medications should have repeat testing within this time frame to follow treatment.
We then queried previously unscreened patients to determine the rate and timing of BMD testing and subsequent fragility fractures after distal forearm fracture.
Table 1ICD-9/Current Procedural Terminology Codes
Billing Codes
Description
Distal radius fractures
ICD-9-D-81340
Closed fracture of lower end of forearm unspecified
ICD-9-D-81341
Closed Colles fracture
ICD-9-D-81342
Other closed fractures of distal end of radius (alone)
ICD-9-D-81343
Closed fracture of distal end of ulna (alone)
ICD-9-D-81344
Closed fracture of lower end of radius with ulna
ICD-9-D-81345
Torus fracture of radius (alone)
ICD-9-D-81346
Torus fracture of ulna (alone)
ICD-9-D-81347
Torus fracture of radius and ulna
ICD-9-D-81350
Open fracture of lower end of forearm unspecified
ICD-9-D-81351
Open Colles fracture
ICD-9-D-81352
Other open fractures of distal end of radius (alone)
ICD-9-D-81353
Open fracture of distal end of ulna (alone)
ICD-9-D-81354
Open fracture of lower end of radius with ulna
Vertebral fractures
ICD-9-D-73313
Pathologic fracture of vertebrae
ICD-9-D-73314
Pathologic fracture of neck of femur
ICD-9-D-73396
Stress fracture of femoral neck
ICD-9-D-80620
Closed fracture of T1-T6 level with unspecified spinal cord injury
ICD-9-D-80621
Closed fracture of T1-T6 level with complete lesion of cord
ICD-9-D-80622
Closed fracture of T1-T6 level with anterior cord syndrome
ICD-9-D-80623
Closed fracture of T1-T6 level with central cord syndrome
ICD-9-D-80624
Closed fracture of T1-T6 level with other specified spinal cord injury
ICD-9-D-80625
Closed fracture of T7-T12 level with unspecified spinal cord injury
ICD-9-D-80626
Closed fracture of T7-T12 level with complete lesion of cord
ICD-9-D-80627
Closed fracture of T7-T12 level with anterior cord syndrome
ICD-9-D-80628
Closed fracture of T7-T12 level with central cord syndrome
ICD-9-D-80629
Closed fracture of T7-T12 level with other specified spinal cord injury
ICD-9-D-80660
Closed fracture of sacrum and coccyx with unspecified spinal cord injury
ICD-9-D-80661
Closed fracture of sacrum and coccyx with complete cauda equina lesion
ICD-9-D-80662
Closed fracture of sacrum and coccyx with other cauda equina injury
ICD-9-D-80669
Closed fracture of sacrum and coccyx with other spinal cord injury
Hip fractures
ICD-9-D-82000
Closed fracture of intracapsular section of neck of femur unspecified
ICD-9-D-82001
Closed fracture of epiphysis (separation) (upper) of neck of femur
ICD-9-D-82002
Closed fracture of midcervical section of neck of femur
ICD-9-D-82003
Closed fracture of base of neck of femur
ICD-9-D-82009
Other closed transcervical fracture of neck of femur
ICD-9-D-82010
Open fracture of intracapsular section of neck of femur unspecified
ICD-9-D-82011
Open fracture of epiphysis (separation) (upper) of neck of femur
ICD-9-D-82012
Open fracture of midcervical section of neck of femur
ICD-9-D-82013
Open fracture of base of neck of femur
ICD-9-D-82019
Other open transcervical fracture of neck of femur
ICD-9-D-82020
Closed fracture of trochanteric section of neck of femur
ICD-9-D-82021
Closed fracture of intertrochanteric section of neck of femur
ICD-9-D-82022
Closed fracture of subtrochanteric section of neck of femur
ICD-9-D-82030
Open fracture of trochanteric section of neck of femur unspecified
ICD-9-D-82031
Open fracture of intertrochanteric section of neck of femur
ICD-9-D-82032
Open fracture of subtrochanteric section of neck of femur
ICD-9-D-8208
Closed fracture of unspecified part of neck of femur
ICD-9-D-8209
Open fracture of unspecified part of neck of femur
ICD-9-D-82100
Closed fracture of unspecified part of femur
BMD
CPT-76977
Ultrasound bone density measurement and interpretation peripheral site(s) any method
We generated survival curves using Kaplan-Meir analysis comparing patients who underwent BMD testing with those who did not. Hip or vertebral fracture was used as the end point. This was used to determine the interval to subsequent fracture. Matched groups based on sex and Charlson Comorbidity Index (CCI) were created and survival curves were again generated. Chi-square analysis was used to compare differences between groups. An α value of 0.05 was used.
Results
A total of 46,992 patients were identified who had sustained a distal forearm fracture (Table 2). Females comprised 81% of the cohort; the largest single age group was aged 85 years and older. Twenty percent of patients had undergone a BMD scan within the previous 2 years. Only 5% of men had screening before fracture, compared with 24% of women (P < .05). The most common fracture billing code was ICD-9-D-81342, which represents a closed fracture of the distal end of radius alone. The annual number of distal forearm fractures decreased every year during the study period (Fig. 1) despite an increasing number of Medicare beneficiaries.
Table 2Demographics of Patients With Distal Forearm Fractures
Previous screening had not been performed in 37,473 patients (Table 3). Of this unscreened group, only 26% had ever undergone BMD testing after the distal forearm fracture. The age groups least likely to be tested after fracture were those aged over 85 years (12%) and less than age 65 years (22%). There was no notable geographic variation. Men were less likely than women to receive postfracture BMD testing (9% vs 30%; P < .05). Figure 2 demonstrates the percentage of patients by age group who had ever undergone BMD testing after fracture. The highest rate of testing was the age group 65 to 69 years, likely owing to the implementation of routine screening at that age. Only 7% of patients underwent testing within 6 months of fracture during the study period (Table 4). Figure 3 demonstrates rates of BMD testing within 6 months of fracture, by year and sex. Overall rates of testing after fracture peaked in 2010.
Table 3Demographics of Patients With DFF Without Previous Osteoporosis Diagnosis or BMD Testing Preceding Fracture
Roughly 1 in 5 patients from both the untested (Table 5) and tested cohorts (Table 6) after fractures went on to a hip or vertebral compression fracture. These patients tended to be older. Patients with testing after fracture had later time to fracture, on average, compared with patients without testing (819 vs 579 days). Survival curves, which account for time to subsequent fracture, were generated with an end point of hip or vertebral fracture. Figures 4 and 5 are the fracture-free interval curves for the CCI-matched cohorts for males and females, respectively. Interestingly, males without subsequent BMD testing had a longer fracture-free interval compared with males tested after the distal forearm fracture. For females, patients in the BMD testing group had an increased fracture-free interval.
Table 5Number of Patients With Subsequent Hip or Vertebral Fractures Without Previous Screening Who Never Had BMD Testing After Fracture
This study found that Medicare patients are not being routinely assessed for osteoporosis after distal forearm fractures. Approximately 1 in 4 patients underwent screening at any time point and less than 1 in 10 underwent testing within 6 months of fracture. Males were particularly undertested. About 1 in 5 patients sustaining these fractures had a subsequent hip or vertebral fracture. On average, patients who underwent testing after distal forearm fracture had improved fracture-free interval to a subsequent hip or vertebral fracture. In the female cohort, this improvement was clearly demonstrated. The male cohort showed the opposite association. It was thought that this finding represented a bias toward BMD testing in particularly ill or frail males. However, with comorbidity-matched cohorts, those with testing after fracture again had a worse fracture-free interval.
This study demonstrates that in the Medicare population, BMD testing in females after distal forearm fractures likely has value in preventing future fractures, or at least delaying them. Presumably, this is due to the pharmacological intervention; however, the ability to assess medication information is beyond the capabilities of this database study. Another confounder is that some surgeons initiate vitamin D and calcium supplementation in patients with distal forearm fractures regardless of BMD results, which could have an impact on future fracture risk.
Other studies demonstrated similar findings regarding low rates of testing and treatment for osteoporosis. Benzvi et al
showed that within a large hospital institution, a cohort of patients with distal radius fragility fractures were infrequently treated for osteoporosis and often sustained secondary fragility fractures. Rozental el al
found that only 21% and 28% of patients received screening or treatment, respectively, after distal radius fracture at their institution. Balasubramanian et al
examined elderly patients in a commercial insurance database and found that only 30% of women and 15% of men underwent testing. The rate was lowest for distal radius fractures. At our institution, Oertel et al
found that male sex was an independent predictor of failure to undergo BMD testing after distal radius fractures and men were about one-third as likely as women to undergo testing.
However, our study did not demonstrate that BMD testing after fracture was associated with improved fracture-free interval in men.
The low rates of testing for patients at both ends of the age spectrum for this cohort are also concerning. Younger patients who receive Medicare do so because of mental or physical health conditions. Most of these patients rate their health status as fair or poor. Many of these have end-stage renal disease and almost one-third have 5 or more chronic health conditions, many of which could have an impact on bone health.
Not addressing bone health in these young patients may increase their risk for fractures, a fact that is not always considered in testing guidelines.
This study also demonstrates low rates of testing among patients over age 85 years. Current guidelines from the National Committee for Quality Assurance recommend testing for osteoporosis after fracture among patients aged 50 to 85 years. Practitioners may be following these or similar guidelines. In addition, patients in this age group may have begun treatment to improve bone health without testing. However, prior studies indicated low rates of both testing and treatment among this age cohort.
These low rates may be due to the lack of consistent data regarding the efficacy of treatment of osteoporosis in this age group. In addition, there are concerns about the safety of medications used to improve BMD. However, the risk for fracture and resulting morbidity and mortality in this population would seem to outweigh concerns regarding treatment side effects.
Although referral for BMD screening has been inadequate, several studies have shown that interventions can improve the rate of screening and treatment. Rozental et al
demonstrated that patients with distal radius fractures were 3 times as likely to undergo testing if the BMD test was ordered by the orthopedic surgeon compared with a letter being sent to the primary care provider, and that patients with BMD screening were 2.5 times more likely to receive treatment for osteoporosis. Sarfani et al
identified patients over age 50 years with a distal forearm fracture who were not screened or treated for osteoporosis. They used a patient educator and referral to endocrinology and found that 80% of these patients were agreeable to screening and 64% went on to receive a diagnosis of osteoporosis or osteopenia after screening. Harness et al
showed that patients who were screened for osteoporosis were 83% less likely to experience a distal forearm fracture than those who were not. This highlights that increased awareness and diligence regarding BMD testing for osteoporosis can have an impact on patient outcomes.
The primary limitation to this study is its retrospective database origin, which depends on proper coding by physicians. We also are unable to verify the mechanisms of injury causing fracture to ensure that they were low-energy. It is possible that some of these injuries were high-energy and not fragility fractures. Individual patient information such as comorbid conditions, race, and socioeconomic status could not be analyzed as potential confounding factors. Finally, we could not determine whether some patients began treatment without obtaining a BMD test. Despite these limitations, this study highlights the low rate of BMD testing after distal forearm fractures among Medicare patients. Women who undergo testing after fracture have improved fracture-free intervals compared with those who do not.
References
Wright N.C.
Looker A.C.
Saag K.G.
et al.
The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine.
American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis - 2016.
30715-2&id=gr1.jpg){kind=link}
30715-2&id=gr2.jpg){kind=link}
30715-2&id=gr3.jpg){kind=link}
30715-2&id=gr4.jpg){kind=link}
30715-2&id=gr5.jpg){kind=link}